Form 5210/02 Legal Support Services (LSS) Provider Invoice for Fees a

OMB Number: 3064-0122
Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation

LEGAL SUPPORT SERVICES (LSS) PROVIDER
INVOICE FOR FEES AND EXPENSES (IF&E)
PAPERWORK REDUCTION ACT NOTICE
Public reporting burden for this collection of information is estimated to average 1.0 hour per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to the Public Reporting Act Clearance Officer, Legal Division, Federal Deposit Insurance
Corporation, 550 17th Street, N.W., Washington, DC 20429, and the Office and Management and Budget, Paperwork Reduction
Project (3064-0122), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number.

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FDIC 5210/02 (5-21)

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OMB Number: 3064-0122
Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation

LEGAL SUPPORT SERVICES (LSS) PROVIDER
INVOICE FOR FEES AND EXPENSES (IF&E)
INSTRUCTIONS: Please provide all requested information.
SECTION I - GENERAL INFORMATION
1. Matter Number

2. Matter Caption

SECTION II - FIRM AND INSTITUTION INFORMATION
3. Financial Institution Name

4. Institution Number

5. Financial Institution Address (City, State, ZIP Code)

6. LSS Provider Name

7. Federal Tax ID Number

8. LSS Provider Address (City, State, ZIP Code)

9. LSS Firm Provider Contact

10. Telephone

11. LSS Firm Provider Accounts Receivable Contact

12. Telephone

13. FDIC Office Location

15. Telephone

14. FDIC Attorney

SECTION III - CURRENT BILLING INFORMATION
16. Invoice Number

17. Billing Period Date
From:

Through:

18. Complete the following billing information
Action

Fees Billed

Expenses Billed

Court Reporting Services
Appraisal Services
Copy/Imaging Services
Escrow Services
Registered Agent Services
Title Company Services
Other Services (Specify):
Fees Invoiced Subtotal:
Expenses Invoiced Subtotal:
Invoice Grand Total:
SECTION IV - CERTIFICATION
I certify that the information contained herein is true and correct to the best of my knowledge and belief, and that all charges for legal
services and disbursements reflected herein are in accordance with our retention agreement with the FDIC Legal Division.
19. Name of LSS Provider

21. Authorized Signature

FDIC 5210/02 (5-21)

20. Title of LSS Provider

22. Date

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